Never Break the Chain: Chain of Referral Issues

1.29.2020 Blog

Medical bills often become an issue at the brink of a workers’ compensation trial or settlement.  On the doorsteps of closure, a new primary care physician, chiropractor or other provider may surface and present an obstacle to closing the claim.  What defenses does a respondent have?  The limitation on claimant’s choice of physicians under Section 8(a) should not be overlooked, and can help to mitigate exposure at the claim’s conclusion.

What treatment is the respondent liable for?

A claimant is entitled to two choices of physicians. If either of those physicians refer claimant to a different treater, treatment within chain of referral constitutes the same “choice.”

Notably, bona fide first aid and urgent medical treatment does not constitute a “choice.”

What if a Preferred Provider Program exists?

If a Preferred Provider Program (PPP) is in place and the injury occurred after June 28, 2011, a claimant’s choice of physician is limited to only one provider outside of the PPP, and the PPP becomes one of claimant’s “choices” of physician.  The PPP must meet certain requirements, discussed in Section 8.1a of the Act.

What is a valid referral?

The Courts have given employees considerable latitude regarding what constitutes a valid referral.  In Absolute Cleaning/SVMBL v. Ill. Workers’ Comp. Comm’n, 409 Ill. App. 3d 463 (4th Dist. 2011), at the urging of claimant and her attorney, claimant’s treating physician referred claimant to a different physician.  The respondent argued since the referral came at claimant’s (or her attorney’s) insistence, this was a “sham” referral to circumvent the two physician rule.  The Court disagreed with respondent, stating, “However, to the extent that Dr. Calloway referred the claimant to certain physicians at the plaintiff’s (or her attorney’s) urging, we note that the genesis of the referral has no bearing on the issue so long as the claimant’s treating doctor ultimately made the referral.” Absolute Cleaning/SVMBL v. Ill. Workers’ Comp. Comm’n, 409 Ill. App. 3d 463, 469 (4th Dist. 2011).

What constitutes a provider?

In Comfort Masters v. Workers’ Compensation Comm’n (Youanis), 382 Ill. App. 3d 1043 (1st Dist. 2008), the issue of whether an acupuncturist was a “provider” under the Act arose.  The claimant suffered a work-related injury and sought treatment through a proper chain of referrals in Illinois.  Thereafter, the claimant sought treatment with an acupuncturist on two occasions.  The acupuncturist was not a licensed chiropractor and performed the services free of charge because of a personal relationship.  Following the treatment with the acupuncturist, claimant moved to New Mexico and sought treatment with a new provider, and subsequently underwent spinal surgery.  Respondent argued treatment with the acupuncturist counted as the second of claimant’s two choices of physicians, and therefore the treatment in New Mexico exceeded claimant’s choice of physician.  The Appellate Court rejected this argument, finding, “The statutory language unequivocally requires treatment by a ‘physician, surgeon or hospital’ to trigger a choice under the two-physician rule. Since [the acupuncturist] was not such a provider, her treatment could not exhaust [petitioner’s] second choice under subsection 8(a)(3).”  Comfort Masters v. Workers’ Compensation Comm’n (Youanis), 382 Ill. App. 3d 1043, 1046 (1st Dist. 2008).

Do providers in the same facility count as additional choices?

Providers in the same clinic, practicing the same medicine, are considered a referral from the original physician, particularly if the practice is sold to a different doctor.  When a practice is sold, the choice is essentially taken out of claimant’s hands.  Therefore, the new physician does not count as an additional choice.  “The Commission found that the claimant selected the clinic as his first medical provider and that it constituted one provider; each subsequent physician was a referral from the prior physician.”  Fencl-Tufo Chevrolet, Inc. v. Industrial Com., 169 Ill. App. 3d 510, 518 (1st Dist. 1988).  “The departure of the single doctor in such an area and subsequent assumption of the practice by another physician does not constitute a discreet choice of physician by claimant.  Rather, these changes represent further links in the chain of referrals arising from claimant’s first choice of the clinic.” Id.

Keeping an eye of the chain of physicians, or lack thereof, is a useful tool to assist in mitigating exposure.  Both parties benefit when medical bills are discussed and shared at every step of the way.  It is claimant’s responsibility to meet all elements of his or her claim, including payment of medical bills.  If you have any questions regarding payment of bills or claimant’s choice of physicians under the Illinois Workers’ Compensation Act, feel free to reach me.

The NBKL blog is provided for informational purposes; we are not giving legal advice or creating an attorney/client relationship by providing this information.  Before relying on any legal information of a general nature, you may consider consulting legal counsel as to your particular facts and applications of the law.